2. NEWS

In letters sent to countries by email on 15 December, the Global Fund provided countries with information on their allocations for 2017-2019. The letters include an indicative split for the three diseases – HIV, TB, and malaria. The Fund encourages programs to support resilient and sustainable systems for health; the funds for such programs will need to be carved out of the allocations for the diseases.

3. NEWS

The Fund has identified 14 initiatives it seeks to enhance the effectiveness of by implementing its Prioritized Action Plan, or PAP. This article explains the PAP, what it monitors and assesses, and elaborates upon the purpose behind it.

4. NEWS

Whether the Secretariat should have a presence in high-risk countries was one of the items discussed at the recent Board meeting in Montreux, Switzerland. This article provides a summary of a paper on the current business model prepared for the meeting.

5. NEWS

Although national supply chain inefficiencies are resulting in a number of significant issues affecting Global Fund operations in-country, the Fund is aware of the problem and is working to resolve the issues. Such issues range from stock-outs and expirations of drugs and supplies, and to overstocking.

6. NEWS

In June 2016, the Strategy Committee determined the process to be used to make qualitative adjustments to the initial allocations derived from the application of the disease burden/income level formula. An article in GFO 301 described the two stages of the process: epidemiological considerations and holistic adjustment. In this article, we provide information on the parameters being used to make the adjustments.

7. NEWS

In February 2016, a second window of Regional Concept Notes, or RCNs, were submitted to the Global Fund. As a result of this process, ICASO and the International HIV/AIDS Alliance conducted six case studies of the respective RCN development. This article highlights the report findings.

8. NEWS and ANALYSIS

This article provides information about how the research of the clinical protocols for opioid substitution therapy supported by the Global Fund, contributes towards sustainability of harm reduction programs in Eastern Europe and Central Asia.

9. NEWS and ANALYSIS

Work carried out by Dr. Abdhalah Ziraba of the African Population and Health Research Center, reveals country actions through Implementation Through Partnership-ITP, or the implementation of country roadmaps, are proving to be successful in addressing absorption bottlenecks and such efforts should be sustained and institutionalized in countries facing significant absorption challenges.

11. NEWS and ANALYSIS

In its final report released last week, the Equitable Access Initiative recommended that a multi-criteria framework be used instead of World Bank income level classifications in policies affecting eligibility for funding and the allocation of resources. The recommendations apply to all donors, not just the Global Fund.

12. NEWS

An Equitable Access Initiative report presents alternatives to the use of income level classification in decisions on eligibility and resource prioritization

11. NEWS and ANALYSIS

19 Dec 2016

Author:

David Garmaise

Multi-criteria framework recommended

From the perspective of the Global Fund, the main takeaway from the final report of the Equitable Access Initiative (EAI) is that decisions on eligibility and prioritization of resources should be based on more than just income level and disease burden. The EAI recommends that a multi-criteria framework be used instead.

The report of the EAI is dated 30 June 2016 but it was not released by the Global Fund until 12 December 2016.

For two decades, the World Bank has classified countries as low-, middle- or high-income based on gross national income (GNI) per capita. GNI has been an important factor in determining the eligibility of countries for development aid. But in recent years, the report said, it has become obvious that relying on the GNI classification has serious limitations.

In the last decade, rapid economic growth has hastened the move from low-income to middle-income status for many countries. In the process, these countries risked losing external support even though they are still home to most of the world’s poorest citizens with unmet health needs.

The EAI was launched in early 2015 by the heads of multilateral organizations engaged in global health: Gavi, the Global Fund, UNAIDS, UNDP, UNFPA, UNICEF, UNITAID, the World Bank, and the WHO. The purpose was to consider alternatives to GNI as a framework to assess countries’ need for external financial support for health.

According to the report, the 105 countries currently considered middle-income are home to more than 75% of the world’s poor, and many of them are characterized by high-levels of inequity. From a global health perspective, the largest share of disease burden is now concentrated in middle-income rather than low-income countries, a reality that GNI per capita alone cannot capture.

The report points out that the recently adopted Sustainable Development Goals (SDGs) call for achieving ambitious development and health goals with an explicit focus on equity, especially among poor and vulnerable populations. One of the unique features of the SDGs, the report said, is in their relevance for all countries regardless of economic standing. But, the report said,

“there is also a renewed commitment to ‘shared responsibility’ in investing toward a more equitable and egalitarian world, and achieving these goals through a human-rights based approach that is rooted in giving all people the opportunity to achieve their right to life and dignity. For external health financing this could mean a greater focus on the social determinants of health, reducing health disparities and the rights of vulnerable groups and key populations.”

The EAI concluded that policymakers should consider a comprehensive framework for decision-making “that accounts for countries’ position on a health development continuum, based on the analysis of countries’ needs, fiscal capacity, and policies.”

More specifically, the EAI study produced the following key findings:

Eligibility – Policies should not only consider the level of wealth in a society, as measured by GNI per capita, but also account for health need relative to income.

Investment priorities – A government’s resources and policies to meet its country’s health need should be taken into account.

Equity – Context-specific analyses are relevant when assessing the level and type of support to be provided.

The Global Fund currently relies heavily on income level and disease burden to determine its policies on eligibility and to arrive at decisions on allocations to countries.

The EAI said that the weight accorded to income level in decisions about eligibility and prioritization overlooked key considerations such as (a) large variations in the distribution of disease; (b) poverty and inequality within countries; (c) the capacity of the health systems within countries; (d) the capacity of governments; and (e) governments’ policy choices towards their citizens.

According to the EAI, another concern is that the income categories themselves are too broad and consist of countries that are sometimes at very different points along the development continuum. The middle-income country category currently ranges from GNI per capita levels of $1,045 to $12,736. Middle-income countries collectively account for the largest global share of poverty and disease, and they have varying levels of development, inequity, political stability, and social issues.

“A framework not purely based on income may be better suited to ease transitions, and identify suitable health interventions,” the EAI said.

The EAI commissioned four expert analytical groups to independently explore the issue. Although their approaches differed, there were significant points of convergence in their recommendations, including (a) the use of disease metrics to capture health need; (b) accounting for inequity in income and health; and (c) accounting for a government’s capacity to domestically finance health. The groups proposed different models. However, the EAI said, all four models provided relatively similar results, “which suggests that health needs and capacities may be captured by a variety of indicators.”

In its report, the EAI described possible indicators and explored the approaches recommended by the four groups. However, the EAI did not recommend a specific framework. A news release issued by the Global Fund implied that the entire EAI report constituted a new policy framework.

The EAI said that although any classification framework depends on both the choice of underlying metric, and the choice of thresholds to group countries along common characteristics, recommending specific thresholds or grouping of counties was beyond the scope of its initiative. It said that the EAI “did not analyze the impacts of discrete funding thresholds on beneficiary country health outcomes, nor did it directly address the types of policies that might be appropriate to mitigate the impacts of eligibility transition.”

The EAI also said that while its work attempted to include inequity measures, the poor quality and the unreliability of the relevant data prevented their inclusion in the overall analysis. “A better understanding of inequity, particularly in health access and outcomes, would require more detailed sub-national analyses and to account for legal and social barriers, for which there is often no regular and reliable data collection,” the EAI said.

Finally, the EAI said that although the analysis and recommendations of its report are specific to health, the fundamental approach and characteristics could have relevance for other areas of development.

The EAI report comes too late to influence in a major way the methodology used to determine the Global Fund’s 2017-2019 allocations. Countries were told last week what their allocations are.